What is Shock

Inadequate blood flow leading to inadequate oxygen

delivery to body tissue May occur with blood loss as little as two points Will result in death unless corrected

Shock
Shock is inadequate tissue perfusion.

Classifications of Shock
Hypovolemic shock
Distributive shock Neurogenic shock Anaphylactic shock Septic shock Cardiogenic shock Obstructive shock

Shock Objectives
1. Define shock 2. Differentiate among hypovolemic,

cardiogenic, anaphylactic, neurogenic, and septic shock. 3. Describe the pathophysiology of shock. 4.Compare the four stages of shock and associated signs and symptoms.

OVERVIEW
Anatomy and Physiology
External Bleeding Internal Bleeding Shock Types of Shock

Hypovolemic Shock
Inadequate tissue perfusion
Causes

Hemorrhage Severe burns Severe vomiting and/or diarrhea

Core Skills

Control Bleeding

Other Common Signs of Hypovolemic Shock

Cold, clammy skin
Cyanosis- nail beds, lips and ear lobes Weak, thready, rapid pulse

Shallow respirations
Oliguria Listlessness, stupor Excessive thirst

Core Skills

Control Bleeding

Hypovolemic Shock
Trauma:
Solid organ injury Pulmonary parenchymal

GI Tract:
Esophageal varices Ulcer disease Gastritis/esophagitis Mallory-Weiss tear Malignancies Vascular lesions

injury Myocardial laceration/rupture Vascular injury Retroperitoneal hemorrhage Fractures Lacerations Epistaxis Burns

Inflammatory bowel disease

Ischemic bowel disease Infectious GI disease Pancreatitis

Hypovolemic Shock
GI Tract: Infectious diarrhea Vomiting Vascular: Aneurysms Dissections AV malformations Reproductive Tract: Vaginal bleeding

Malignancies Miscarriage Metrorrhagia Retained products of conception Placenta previa

Ectopic Pregnancy Ruptured ovarian cyst

Function of Blood
Transport O and nutrients to the cells
Removes CO and other waste products Detoxification and elimination

Core Skills

Control Bleeding

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Clinical Signs of Acute Hemorrhage

Class % Blood Loss Clinical Signs

I II III IV

Up to 750 ml Slight increase in HR; no change in BP or (15%) respirations 750-1500 ml Increased HR and respirations; increased (15-30%) diastolic BP; anxiety, fright or hostility 1500-2000 Increased HR and respirations; fall in ml (30-40%) systolic BP; significant AMS >2000 (>40%)
Core Skills

Severe tachycardia; severe lowering of BP; cold, pale skin; severe AMS
Control Bleeding 12

Haemorrhagic shock
Four Classes (I- IV)
Begin therapy as soon as possible

Oxygen Surgeon* to stop the bleeding Fluids to restore circulation

*sometimes a physician if a GI bleed

Other Common Signs of Hypovolemic Shock

Cold, clammy skin
Cyanosis- nail beds, lips and ear lobes Weak, thready, rapid pulse

Shallow respirations
Oliguria Listlessness, stupor, LOC Excessive thirst

Core Skills

Control Bleeding

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Compensated Shock

Figure 19-3

Uncompensated Shock
Characterized by signs and symptoms of late shock
Arterial blood pressure is abnormally low Treatment at this stage will sometimes result in

recovery

Uncompensated Shock

Figure 19-4

Irreversible Shock
Characterized by signs and symptoms of late shock
Arterial blood pressure is abnormally low Even aggressive treatment at this stage does not result

in recovery

Irreversible Shock

Figure 19-5

Management and Treatment Plan for the Shock Patient

Goals of prehospital care Ensure a patent airway Provide adequate oxygenation and ventilation Restore perfusion

Initial Assessment
Airway
Breathing Circulation

Disability
Expose body surfaces

Differential Shock Assessment Findings

Shock is assumed to be hypovolemic until proven otherwise
Cardiogenic shock
Differentiated from hypovolemic shock by one or more

of the following:

Chief complaint (chest pain, dyspnea, tachycardia) Heart rate (bradycardia or excessive tachycardia) Signs of congestive heart failure (jugular vein distention, rales) Dysrhythmias

Differential Shock Assessment Findings

Distributive shock Differentiated from hypovolemic shock by presence of one or more of following:

Mechanism that suggests vasodilation, e.g., spinal cord injury, drug overdose, sepsis, anaphylaxis Warm, flushed skin (especially in dependent areas) Lack of tachycardia response (not reliable)

Differential Shock Assessment Findings

Obstructive shock Differentiated from hypovolemic shock by presence of signs and symptoms suggestive of:

Cardiac tamponade Tension pneumothorax Pulmonary embolism

Detailed Physical Examination

Vital signs Pulse Blood pressure Orthostatic vital signs Evaluate patients ECG

Resuscitation
Resuscitation is aimed at restoring adequate

peripheral tissue oxygenation as quickly as possible This is accomplished by:

Ensuring adequate oxygenation Maintaining an effective ratio of volume to container

size Rapidly transporting the victim to an appropriate medical facility

Red Blood Cell Oxygenation

First requirement for adequate tissue oxygenation
For adequate red blood cell oxygenation:
The patient must have a patent airway Ventilation must be supported with high FiO2 If necessary, ventilations should be assisted with positive

pressure Correct any airway abnormalities that interfere with adequate ventilation

Ratio of Volume to Container Size

Adequate oxygen-carrying capacity requires that the

container be full of fluid May be accomplished by:

Decreasing size of container Especially in shock states not associated with hemorrhage Possible use of vasoactive medications in some cases of

distributive shock Volume replacement may be necessary

Crystalloids
Solutions created by dissolving crystals (such as sugars

and salts) in water

Less osmotic pressure than colloids Can be expected to equilibrate more quickly between

the vascular and extravascular spaces

Two-thirds of infused crystalloid fluid leaves the vascular space within 1 hour 3 mL of a crystalloid solution is needed to replace 1 mL of blood

Hypertonic & Hypotonic Solutions

Hypertonic solutions
Have higher osmotic pressure than that of body cells 5% dextrose in 0.9% sodium chloride 7.5% saline 5% dextrose in 0.45% sodium chloride

Hypotonic solutions
Have a lower osmotic pressure than that of body cells Distilled water 0.45% sodium chloride (0.45% NaCl)

Isotonic Solutions
Lactated Ringer's solution
Normal saline Glucose-containing solutions (e.g., D5W)

Colloids
Solutions that contain molecules (usually protein) that are too large to pass through the capillary membrane Exhibit osmotic pressure and remain within the vascular compartment for a considerable length of time Examples
Whole blood Plasma Packed red blood cells

Key Principles in Managing Shock

Establish and maintain an open airway Administer high-concentration oxygen, and assist ventilation as needed Control external bleeding (if present) Initiate IV fluid replacement if appropriate Consider use of PASG (per protocol) Maintain patient's normal body temperature Monitor cardiac rhythm and oxygen saturation Frequently reassess vital signs

Hypovolemic Shock
Treatment is not considered complete until the

circulatory deficit and its causes are corrected

Crystalloid fluid replacement for simple dehydration Volume replacement for hemorrhage Definitive surgery Critical care support Postoperative rehabilitation

Integration of Patient Assessment and the Treatment Plan

The goals of prehospital care for the patient with

severe hemorrhage or shock include:

Rapid recognition of the event Initiation of treatment

Prevention of additional injury

Rapid transport to an appropriate medical facility by

ground or air ambulance Advance notification of the receiving facility

Cardiogenic Shock
Treatment is directed toward improving the pumping action of the heart and managing cardiac rhythm irregularities
Fluid replacement

Drug therapy (varies by cause)

Patients with cardiogenic shock secondary to

myocardial ischemia or infarction require:

Reperfusion strategies Possible circulatory support

Tension pneumothorax and cardiac tamponade must be

managed immediately

Neurogenic Shock
Treatment is similar to treatment for hypovolemia Care must be taken during IV therapy to avoid circulatory overload Closely monitor lung sounds for pulmonary congestion Use of vasopressors may be indicated

Anaphylactic Shock
Subcutaneous administration of epinephrine is treatment of choice in acute anaphylactic reactions Depending on severity, other therapy may include:
Oral, IV, or IM administration of antihistamines Bronchodilators to treat bronchospasm Steroids to reduce the inflammatory response Crystalloid volume replacement Aggressive airway management should be anticipated

Septic Shock
Treatment may include the management of hypovolemia (if present) and the correction of metabolic acid-base imbalance
Prehospital care may include:
Fluid resuscitation Respiratory support Vasopressors to improve cardiac output Obtain a thorough history to help determine the source

of the sepsis

General Treatment of Shock

Assure airway
Administer oxygen Assist ventilations if necessary. Position patient to assist perfusion. (elevate head and

shoulders if pulmonary edema.) Keep patient warm. Perform a Focused history and physical. Adjust O2, Gain IV access, ECG monitor, Pulse Oximetry.

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Advanced Care Hypovolemic Shock

Large bore IV: Minimum 18 gage

Preferably 14 or 16 gage
Use blood tubing if available or macro tubing apply pressure to bag

to speed infusion
Fluid Replacement: Lactated Ringers or Normal Saline (Make sure

fluids are warm

Need 3 liter fluid to replace 1 liter blood loss, titrate fluid infusion

to the B/P.

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Summery
Shock is a syndrome.
Golden minute principle:no more than 10 min on scene, Rapid diagnosis and field stabilization is

critical. Golden hour principle: Shock must be stopped within one hour of cause. Treat during transport when ever possible.

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